Medicare Compliance & Reimbursement

Hint: Medicare pay may be adjusted based on your performance.

CMS continues to churn out policy after policy, cutting the administrative burdens commonly associated with Medicare while simultaneously putting more of the financial onus on providers.

The agency’s most recent iteration, the “Primary Care Initiative,” is another cost-savings, pro-patient venture that may or may not pay off for savvy providers.

In the past, “acute-care providers” were the targets of “bundled payment models,” suggest attorneys Kristen Barlow and Alissa Smith of Dorsey and Whitney LLP, in the Dorsey Health Law blog. On a secondary level, individual providers did benefit from those models, but the Centers for Medicare and Medicaid Services (CMS) Primary Care Initiative is different.

Now, “the physician [is] front and center of owning responsibility for the cost and quality of their patients’ care — an acknowledgement from CMS that primary care providers and close patient interaction are linchpins for sustained success in transitioning toward better outcomes for the health of a population,” Barlow and Smith warn.

Review the 2 Primary Care First Payment Model Options

The Primary Care First (PCF) path “is based on the underlying principles of the existing CPC+ model design,” CMS says. But, the new PCF payment models offer greater rewards for taking on more risks than the previous Center for Medicare and Medicaid Innovation (CMMI) models.

In a nutshell, the two models under the PCF path “incentivize providers to reduce hospital utilization and total cost of care by potentially rewarding them through performance-based payment adjustments,” explain attorneys Michael B. Lampert, Samuel Perrone, and Ivette Sanchez of national law firm Ropes & Gray LLP in online analysis of the payment models.

Here are the key takeaways from the two PCF options:

1. PCF-General: This basic payment model will utilize a monthly payment to practices delivering on their promises “to offer advanced primary care in and outside of the office,” CMS says. Administrative burdens will be cut and payment increases will be granted for taking on riskier patients. “A total monthly payment that includes a population-based payment along with a flat primary care visit fee, and a performance-based adjustment providing an upside of up to 50 percent of revenue as well as a small downside (10 percent of revenue), [will be] assessed and paid quarterly,” Lampert, Perrone, and Sanchez write.

2. PCF-High Need Populations: This payment option is a Seriously Ill Population (SIP) model, under which Medicare will “attribute” patients lacking a primary care practitioner to a SIP practice, CMS says. “Payment amounts for SIP patients will be set to reflect the high need, high risk nature of the population as well as include an increase or decrease in payment based on quality,” the agency continues.

Moreover, “clinicians enrolled in Medicare who typically provide hospice or palliative care services (e.g., those affiliated with a hospice, palliative care or similar organization) will be able to provide care for SIP patients either by participating as a practice in the Primary Care First general payment model option or by partnering with a Primary Care First practice participating in the general payment model option that includes these clinicians on their roster of participating practitioners,” CMS explains.

Eligibility requirements: To be considered eligible, you must care for at least 125 attributed Medicare beneficiaries as a primary care practitioner and be located in one of the PCF designated regions. Remember, CMS identifies primary care practitioners as either an “MD, DO, CNS, NP,” or “PA certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine,” agency guidance notes.

In addition, 70 percent of your revenue must be from primary care services, and you must also have experience in participating in a value-based payment program like the Quality Payment Program, the Medicare Shared Savings Program, or other similar program.

Lastly, as long as you use 2015 Edition Certified EHR Technology and can attest in a “Practice Application to a limited set of advanced primary care delivery capabilities,” plus meet any miscellaneous PCF Participation Agreement requirements, the PCF path and one of the two payment models might be for you.

Resource: Check out the PCF models at www.cms.gov/newsroom/fact-sheets/primary-care-first-foster-independence-reward-outcomes.